TB briefing: Embrace risk to improve case detection

How do you reach the three million people who become ill with tuberculosis every year, but go undetected, suffering and dying needlessly, while infecting others? The answer is simple: take a risk. TB REACH, a program of the Stop TB Partnership, has embraced the “inherent risk of innovation” to find new, more effective approaches to TB case detection, which are tailored uniquely to reach different vulnerable populations.

At a World Bank briefing on Monday, representatives from TB REACH described innovative TB case detection strategies that have successfully detected thousands of active TB cases that would have gone undetected otherwise, in the hardest hit places. With support from the Canadian International Development Agency and UNITAID, TB REACH – launched in 2010 – has issued 109 grants in 44 countries to programs that use novel case detection techniques in areas with limited or non-existent TB care and support services.

Aamir Khan, director of the Indus Hospital Research Center in Karachi, Pakistan, described how with support from TB REACH, the Indus Hospital has doubled the number of TB cases it’s reported, thanks to community health workers and a public-private partnership. Despite higher costs, most Pakistani patients – even the very poor – seek care in the private sector because of better hours, shorter wait times, ease of access, and a perception that they’ll receive better care than in the public sector. Khan pointed out that free TB programs often come with hidden costs, such as the cost of transportation and lost wages from taking time off from work to seek services during regular hours.

To address this challenge, Khan and his colleagues used their grant from TB REACH to link up private clinics with the Indus Hospital, which has a public TB treatment facility. They placed community health workers in the waiting rooms of private clinics, where health workers identified potential TB patients and referred them to the hospital if they were found to be symptomatic. Health workers used smartphones to screen and track patients using national ID cards, and ensure their registration in the public health database. In one year they doubled TB case notification rates in a population of more than one million people, while the private sector saw an increase in business thanks to a communication campaign that directed patients to select private clinics.

Health workers were given a monthly stipend of $30, but also received additional performance incentives, so that the median monthly income is $49, with some workers earning up to $500 a month. “Forty-nine dollars looks like a lot of money to me in some of these settings,” panelist Amanda Glassman, director for global health policy at the Center for Global Development, said.

Less than two dollars a day, forty nine dollars is “not exactly rolling in the dough,” Mandy Slutsker of ACTION pointed out, adding that money yields exponentially positive results in terms of case detection. Detecting TB is also preventing TB, she said, because a single undetected TB patient can infect 10-15 people per year.

“It’s not a lot of money but it is enough to keep unemployed young people motivated,” Suvanand Sahu of the Stop TB Secretariat said.

Daniel Datiko of the TB REACH Ethiopia project described how in the rural areas of Ethiopia, where access to TB diagnostic and treatment services is limited, TB REACH trains healthcare workers in villages to identify TB symptomatic people in their homes, collect sputum, prepare smears, and contact supervisors who visit up to 42 villages per month using motorbikes, collecting sputum samples to be analyzed in labs. At the end of the second year, they had screened over 100,000 people and found and treated over 9,000 cases. While doubling their case detection and improving treatment outcomes, particularly among women, children, the disabled, and the elderly, they also improved TB awareness and reduced stigma.

A similar TB REACH program in rural Tanzania employs a mobile laboratory in a van which uses the rapid diagnostic machine GeneXpert, and also doubles as a movie theater to attract more patients. This is the first time GeneXpert has been used at the community level at rural health centers, and in a mobile van. TB case detection increased by 85% in one year.

“The answer to TB is prevention,” Phillip Nieburg with the Center for Strategic and International Studies said, adding that case detection is essesntial to prevention..

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